Chlorpromazine
Clinical data | |
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Trade names | Largactil, Thorazine, Sonazine, others |
AHFS/Drugs.com | Monograph |
MedlinePlus | a682040 |
License data | |
Pregnancy category |
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Routes of administration | By mouth, rectal, intramuscular, intravenous |
Drug class | Typical antipsychotic |
ATC code | |
Legal status | |
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Pharmacokinetic data | |
Bioavailability | 10–80% (Oral; large interindividual variation)[5] |
Protein binding | 90–99%[5] |
Metabolism | Liver, mostly CYP2D6-mediated[5] |
Elimination half-life | 30 hours[6] |
Excretion | Kidney (43–65% in 24 hrs)[5] |
Identifiers | |
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Chlorpromazine (CPZ), marketed under the brand names Thorazine and Largactil among others, is an
Chlorpromazine is in the
Common side effects include movement problems, sleepiness, dry mouth, low blood pressure upon standing, and increased weight.[6] Serious side effects may include the potentially permanent movement disorder tardive dyskinesia, neuroleptic malignant syndrome, severe lowering of the seizure threshold, and low white blood cell levels.[6] In older people with psychosis as a result of dementia it may increase the risk of death.[6] It is unclear if it is safe for use in pregnancy.[6]
Chlorpromazine was developed in 1950 and was the first antipsychotic on the market.
Medical uses
Chlorpromazine is used in the treatment of both acute and chronic psychoses, including schizophrenia and the manic phase of bipolar disorder, as well as amphetamine-induced psychosis.
In a 2013 comparison of fifteen antipsychotics in schizophrenia, chlorpromazine demonstrated mild-standard effectiveness. It was 13% more effective than lurasidone and iloperidone, approximately as effective as ziprasidone and asenapine, and 12–16% less effective than haloperidol, quetiapine, and aripiprazole.[13]
A 2014 systematic review carried out by Cochrane included 55 trials that compared the effectiveness of chlorpromazine versus placebo for the treatment of schizophrenia. Compared to the placebo group, patients under chlorpromazine experienced less relapse during 6 months to 2 years follow-up. No difference was found between the two groups beyond two years of follow-up. Patients under chlorpromazine showed a global improvement in symptoms and functioning. The systematic review also highlighted the fact that the side effects of the drug were 'severe and debilitating', including sedation, considerable weight gain, a lowering of blood pressure, and an increased risk of acute movement disorders. They also noted that the quality of evidence of the 55 included trials was very low and that 315 trials could not be included in the systematic review due to their poor quality. They called for further research on the subject, as chlorpromazine is a cheap benchmark drug and one of the most used treatments for schizophrenia worldwide.[14]
Chlorpromazine has also been used in
Other
Chlorpromazine is occasionally used off-label for treatment of severe
In Germany, chlorpromazine still carries label indications for
Chlorpromazine and other phenothiazines have been demonstrated to possess antimicrobial properties, but are not currently used for this purpose except for a very small number of cases. For example, Miki et al. 1992 trialed daily doses of chlorpromazine, reversing
Chlorpromazine is an
Measured outcome | Findings summary | Findings range | Quality of evidence |
---|---|---|---|
Global effects | |||
No improvement (9 weeks – 6 months) | 30% less risk of having no improvement in mental state, behaviour and functioning | RR 0.7 CI 0.6 to 0.9 | Very low (estimate of effect uncertain) |
Relapse (6 months – 2 years) | 35% less risk of relapse | RR 0.7 CI 0.5 to 0.9 |
Adverse effects
There appears to be a dose-dependent risk for seizures with chlorpromazine treatment.[26] Tardive dyskinesia (involuntary, repetitive body movements) and akathisia (a feeling of inner restlessness and inability to stay still) are less commonly seen with chlorpromazine than they are with high potency typical antipsychotics such as haloperidol[27] or trifluoperazine, and some evidence suggests that, with conservative dosing, the incidence of such effects for chlorpromazine may be comparable to that of newer agents such as risperidone or olanzapine.[28]
Chlorpromazine may deposit in ocular tissues when taken in high dosages for long periods of time.
Measured outcome | Findings summary | Findings range | Quality of evidence |
---|---|---|---|
Adverse effects | |||
Weight gain | 5 times more likely to have considerable weight gain, around 40% with chlorpromazine gaining weight | RR 4.9 CI 2.3 to 10.4 | Very low (estimate of effect uncertain) |
Sedation | 3 times more likely to cause sedation, around 30% with chlorpromazine | RR 2.8 CI 2.3 to 3.5 | |
Acute movement disorder | 3.5 times more likely to cause easily reversible but unpleasant severe stiffening of muscles, around 6% with chlorpromazine | RR 3.5 CI 1.5 to 8.0 | |
Parkinsonism | 2 times more likely to cause parkinsonism (symptoms such as tremor, hesitancy of movement, decreased facial expression), around 17% with chlorpromazine | RR 2.1 CI 1.6 to 2.8 | |
Decreased blood pressure with dizziness | 3 times more likely to cause decreased blood pressure and dizziness, around 15% with chlorpromazine | RR 2.4 CI 1.7 to 3.3 |
Contraindications
Absolute contraindications include:[5]
- Circulatory depression
- CNS depression
- Coma
- Drug intoxication
- Bone marrow suppression
- Phaeochromocytoma
- Hepatic failure
- Active liver disease
- Previous hypersensitivity (including jaundice, agranulocytosis, etc.) to phenothiazines, especially chlorpromazine, or any of the excipients in the formulation being used.
Relative contraindications include:[5]
- Epilepsy
- Parkinson's disease
- Myasthenia gravis
- Hypoparathyroidism
- Prostatic hypertrophy
Very rarely, elongation of the QT interval may occur, increasing the risk of potentially fatal arrhythmias.[29]
Interactions
This section may require cleanup to meet Wikipedia's quality standards. The specific problem is: Too much use of "also"; unclear structure/organization, especially due to heavy reliance on one source. (January 2022) |
Consuming food prior to taking chlorpromazine orally limits its absorption; likewise, cotreatment with
Chlorprozamine is also a moderate inhibitor of
Chlorpromazine may also interact with
Other drugs that prolong the QT interval, such as quinidine, verapamil, amiodarone, sotalol and methadone, may also interact with chlorpromazine to produce additive QT interval prolongation.[5]
Discontinuation
The British National Formulary recommends a gradual withdrawal when discontinuing antipsychotics to avoid acute withdrawal syndrome or rapid relapse.[30] Symptoms of withdrawal commonly include nausea, vomiting, and loss of appetite.[31] Other symptoms may include restlessness, increased sweating, and trouble sleeping.[31] Less commonly, there may be a feeling of the world spinning, numbness, or muscle pains.[31] Symptoms generally resolve after a short period of time.[31]
There is tentative evidence that discontinuation of antipsychotics can result in psychosis.[32] It may also result in reoccurrence of the condition that is being treated.[33] Rarely, tardive dyskinesia can occur when the medication is stopped.[31]
Pharmacology
Chlorpromazine is classified as a low-potency typical antipsychotic. Low-potency antipsychotics have more anticholinergic side effects, such as dry mouth, sedation, and constipation, and lower rates of extrapyramidal side effects, while high-potency antipsychotics (such as haloperidol) have the reverse profile.[15]
Pharmacodynamics
Site | Ki | Species | Ref |
---|---|---|---|
5-HT1A | 3115 | Human | [34] |
5-HT1B | 1,489 | Human | [35] |
5-HT1D | 452 | Human | [35] |
5-HT1E | 344 | Human | [35] |
5-HT2A | 2.75 | Human | [36] |
5-HT2C | 25 | Human | [37] |
5-HT3 | 776 | Human | [38] |
5-HT5A | 118 | Human | [35] |
5-HT6 | 19.5 | Human | [38] |
5-HT7 | 21 | Human | [35] |
α1A | 0.28 | Human | [35] |
α1B | 0.81 | Human | [35] |
α2A | 184 | Human | [35] |
α2B | 28 | Human | [35] |
α2C | 46 | Human | [35] |
β1 | >10,000 | Human | [35] |
β2 | >10,000 | Human | [35] |
M1 | 47 | Human | [35] |
M2 | 433 | Human | [35] |
M3 | 47 | Human | [35] |
M4 | 151 | Human | [35] |
D1 | 114.8 | Human | [38] |
D2 | 7.244 | Human | [38] |
D3 | 6.9 | Human | [39] |
D4 | 32.36 | Human | [38] |
H1 | 4.25 | Human | [39] |
H2 | 174 | Human | [35] |
H3 | 1,000 | Human | [39] |
H4 | 5,048 | Human | [35] |
NET | 2,443 | Human | [35] |
DAT | >10,000 | Human | [35] |
Chlorpromazine is a very effective antagonist of
Chlorpromazine acts as an antagonist (blocking agent) on different postsynaptic and presynaptic receptors:
- Dopamine receptors (subtypes D1, D2, D3 and D4), which account for its different antipsychotic properties on productive and unproductive symptoms, in the mesolimbic dopamine system accounts for the antipsychotic effect whereas the blockade in the nigrostriatal system produces the extrapyramidal effects
- extrapyramidal side effects, but also leading to weight gain and ejaculation difficulties.
- Histamine receptors (H1 receptors, accounting for sedation, antiemetic effect, vertigo, and weight gain)
- α1- and α2-adrenergic receptors (accounting for sympatholytic properties, lowering of blood pressure, reflex tachycardia, vertigo, sedation, hypersalivation and incontinence as well as sexual dysfunction, but may also attenuate pseudoparkinsonism – controversial. Also associated with weight gain as a result of blockage of the adrenergic alpha 1 receptor as well as with intraoperative floppy iris syndrome due to its effect on the iris dilator muscle.[40]
- electrocardiographic changes and loss of memory, but the anticholinergic action may attenuate extrapyramidal side effects).[medical citation needed]
The presumed effectiveness of the antipsychotic drugs relied on their ability to block dopamine receptors. This assumption arose from the dopamine hypothesis that maintains that both schizophrenia and bipolar disorder are a result of excessive dopamine activity. Furthermore, psychomotor stimulants like cocaine that increase dopamine levels can cause psychotic symptoms if taken in excess.[41]
Chlorpromazine and other typical
Chlorpromazine and other antipsychotics with
In addition to influencing the neurotransmitters dopamine, serotonin,
Chlorpromazine does also act as a FIASMA (functional inhibitor of acid sphingomyelinase).[45]
Peripheral effects
Chlorpromazine is an antagonist to H1 receptors (provoking antiallergic effects), H2 receptors (reduction of forming of gastric juice), M1 and M2 receptors (dry mouth, reduction in forming of gastric juice) and some 5-HT receptors (different anti-allergic/gastrointestinal actions).[medical citation needed]
Because it acts on so many receptors, chlorpromazine is often referred to as a "
Pharmacokinetics
Bioavailability | tmax | CSS | Protein bound | Vd | t1/2 | Details of metabolism | Excretion | Notes |
---|---|---|---|---|---|---|---|---|
10–80% | 1–4 hours (Oral); 6–24 hours (IM) | 100–300 ng/mL | 90–99% | 10–35 L/kg (mean: 22 L/kg) | 30±7 hours | CYP2D6, CYP1A2—mediated into over 10 major metabolites.[15] The major routes of metabolism include hydroxylation, N-oxidation, sulfoxidation, demethylation, deamination and conjugation. There is little evidence supporting the development of metabolic tolerance or an increase in the metabolism of chlorpromazine due to microsomal liver enzymes following multiple doses of the drug.[48] | Urine (43–65% after 24 hours) | Its high degree of lipophilicity (fat solubility) allows it to be detected in the urine for up to 18 months.[5][49] Less than 1% of the unchanged drug is excreted via the kidneys in the urine, in which 20–70% is excreted as conjugated or unconjugated metabolites, whereas 5–6% is excreted in feces.[49] |
History
In 1933, the French pharmaceutical company
Chlorpromazine was distributed for testing to physicians between April and August 1951. Laborit trialled the medicine on at the Val-de-Grâce military hospital in Paris, using it as an anaesthetic booster in intravenous doses of 50 to 100 mg on surgery patients and confirming it as the best drug to date in calming and reducing shock, with patients reporting improved well being afterwards. He also noted its hypothermic effect and suggested it may induce artificial hibernation. Laborit thought this would allow the body to better tolerate major surgery by reducing shock, a novel idea at the time. Known colloquially as "Laborit's drug", chlorpromazine was released onto the market in 1953 by Rhône-Poulenc and given the trade name Largactil, derived from large "broad" and acti* "activity".[7]
Following on, Laborit considered whether chlorpromazine may have a role in managing patients with severe burns,
Pierre Deniker had heard about Laborit's work from his brother-in-law, who was a surgeon, and ordered chlorpromazine for a clinical trial at the Sainte-Anne Hospital Center in Paris where he was Men's Service Chief.[7] Together with the Director of the hospital, Jean Delay, they published their first clinical trial in 1952, in which they treated 38 psychotic patients with daily injections of chlorpromazine without the use of other sedating agents.[53] The response was dramatic; treatment with chlorpromazine went beyond simple sedation with patients showing improvements in thinking and emotional behaviour.[54] They also found that doses higher than those used by Laborit were required, giving patients 75–100 mg daily.[7]
Deniker then visited America, where the publication of their work alerted the American psychiatric community that the new treatment might represent a real breakthrough. Heinz Lehmann of the
Chlorpromazine largely replaced electroconvulsive therapy, hydrotherapy,[59] psychosurgery, and insulin shock therapy.[54] By 1964, about 50 million people worldwide had taken it.[60] Chlorpromazine, in widespread use for 50 years, remains a "benchmark" drug in the treatment of schizophrenia, an effective drug although not a perfect one.[25]
Society and culture
In Literature
Thorazine was often depicted in Tom Wolfe's The Electric Kool-Aid Acid Test to abort bad trips on LSD. Thorazine is also mentioned in Fear and Loathing in Las Vegas, where it was reported to have similar effects to those on LSD.
Names
Brand names include Thorazine, Largactil, Hibernal, and Megaphen (sold by Bayer in West-Germany since July 1953).[61]
Research
Chlorpromazine has tentative benefit in animals infected with Naegleria fowleri,[62] and shows antifungal and antibacterial activity in vitro.[63][clarification needed]
Veterinary use
The veterinary use of chlorpromazine has generally been superseded by use of acepromazine.[64]
Chlorpromazine may be used as an antiemetic in dogs and cats, or, less often, as sedative before anesthesia.[65] In horses, it often causes ataxia and lethargy, and is therefore seldom used.[64][65]
It is commonly used to decrease nausea in animals that are too young for other common anti-emetics.[
The use of chlorpromazine in food-producing animals is not permitted in the EU, as a maximum residue limit could not be determined following assessment by the European Medicines Agency.[66]
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